Iranian Journal of Pharmaceutical Research (2014),13 (supplement): 217-224 Copyright © 2014 by School of Pharmacy Received: November 2013 Shaheed Beheshti University of Medical Sciences and Health Services Accepted: December 2013
Original Article
Drug Literacy in Iran: the Experience of Using “The Single Item Health Literacy Screening (SILS) Tool”
Farzad Peiraviana*, Hamid Reza Rasekha, Hasan Jahani Hashemib, Navid Mohammadic, Nahid Jafarid and Kianoosh Fardie
aDepartment of Phamacoeconomics and Pharmaceutical Management, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran. bDepartment of Biostatistics, School of Medicine, Qazvin University of Medical Sciences, Qazvin, Iran. cDepartment of Community Medicine, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran. dHealth Management Network Center, Ministry of Health and Medical Education, Iran. eDeputy of Food and Drug, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Abstract
Drug and health literacy is a key determinant of health outcomes. There are several tools to assess drug and health literacy. The objective of this article is to determine drug literacy level and its relationships with other factors using a single item screening tool. A cross- sectional survey was conducted among 1104 people in Qazvin province, Iran. Based on the proportional-to-size method, participants over 15 years old with ability to read were recruited randomly from 6 counties in Qazvin province and were interviewed directly. To determine drug literacy relationship with other variables, Chi-Square and t-test were used. Also, logistic regression model was used to adjust the relationship between drug literacy and other relevant variables. Response rate in clusters was 100%. Findings showed that inadequate drug literacy in Qazvin province is 30.3% and it was in association with (1) age (p = .000), (2) marital status (p = .000), (3) educational attainment (p = .000), (4) home county (p = .000), (5) residing area (p = .000), (6) type of basic health insurance (p = .000), (7) complementary health insurance status (p = .000), and (8) family socioeconomic status (p = .000). After adjusting for these variables using logistic regression model, the association between (1), (3), (4), (5) and (8) with drug literacy level was confirmed. The analysis also showed that this method can also be used in other health care settings in Iran for drug and health literacy rapid assessment.
Keywords: Drug literacy; Screening tools; Educational status; Health education; Assessment tools.
Introduction and services needed to make appropriate health decisions”(1,2,3). Obviousely, besed on health The“health literacy” term was first used in the literacy definition, drug literacy could be defined 1970s . According to The Patient Protection and as a subgroup of health literacy. Affordable Care Act, health literacy is defined as There are some disagreements between “the degree of capacity of individuals to obtain, researchers about the differences between literacy process, and understand basic health information and health literacy and scope of each of them. Some researchers believe that health literacy is * Corresponding author: literacy in the health area, while some others think E-mail:[email protected] that health literacy and literacy are separate (4). Peiravian F et al. / IJPR (2014), 13 (supplement): 217-224
Many studies have shown the prevalence of Estimate of Adult Literacy in Medicine–Short limited health literacy in countries (5). A study in Form (REALM-SF), Short Assessment of Health the United States found that 14% of the 19,000 Literacy for Spanish Adults (SAHLSA-50), and participants had below basic, 22% had basic, the Medical Terminology Achievement Reading over half (53%) had intermediate, and 12% had Test (MART); proficient health literacy (6). 2- Reading comprehension tests, which are Evidences have shown the relationships mostly used in educational settings; between health literacy and health status; 3- Functional health literacy tests: Test of amount and pattern of use of health services; Functional Health Literacy in Adults knowledge and ability to manage chronic (TOFHLA), and the Newest Vital Sign diseases and adherence to treatment and (NVS); and, medication use (7). It is important to know 4- Informal methods (32). that even after adjusting for some demographic Time is a very important component in variables such as age, gender, race, and socio- assessing health literacy in the health care economic status, the relationships still hold (8, setting. Informal methods are the most common 9, 10 and 11) and are identified well (12). methods to assess health literacy. Usually, they Moreover, evidence has shown the consist of some questions to estimate health relationship between inadequate health literacy level. In comparison with other methods, literacy and utilization pattern of health care they need less time to be utilized (33). Chew and services such as higher use of emergency colleagues (26). defined 3 questions to assess health care services, lower use of preventive inadequate health literacy. Those questions services, difficulties with medication dosages were successful in identifying individuals with and understanding health messages (13,14), poor reading ability in comparison with Short reporting illness and perceptions of illnesses Test of Functional Health Literacy in Adults and diseases (15). (S-TOFHLA)(25,34) a gold standard health In medication field, 20- 50% of patients do literacy instrument (33). not take their medication as their physicians The 3 Questions were: have prescribed, which might lead to medication - “How confident are you in filling out medical nonadherence. Inadequate health literacy had forms by yourself?”, been considered as one of the most important - “How often do you have someone help you key factors for medication nonadherence (16). read hospital materials?”, and More than half of patients with inadequate - “How often do you have problems in health literacy could not understand medicines learning about your medical condition instruction correctly (17). Misinterpretation of because of difficulty in understanding written prescription drug labels is doubled in patient information?” with low literacy (8). Patients select 1 of 5 responses ranging from On the other hand, individuals with adequate 1- Never to 5- Always (26, 32, 35). health literacy can use their skills of reading, Wallace and colleagues suggested that 1 numeracy, and writing, for health-related question of these 3 questions might be sufficient subjects within the health-care settings (18). for detecting limited and marginal health literacy Strong link between education and health has (23). led researchers to focus on reading skills and Morris and colleagues designed a single health related outcomes like health knowledge, question,“How often do you need to have someone medication adherence, and hospitalization rates help you when you read instructions, pamphlets, (19, 20). or other written material from your doctor or There are many tools to assess health literacy pharmacy?”, to assess poor literacy level. They (8, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 and 31) found that this method can assess limited health The main categories of these tools are: literacy moderately well in comparison with 1- Word recognition tests: Wide Range TOFHLA as gold standard (33). Jeppsen and Achievement Test–Revised (WRAT-R), Rapid colleagues found that the above question is one
218 Health Literacy in Iran: The Experience of Using “The Single Item Health of the measures that can independently predict literacy screening sensitivity. Scores greater limited health literacy (29). than 2 were considered positive, which meant Most studies in assessing health literacy are participant had inadequate drug literacy. To conducted in English speaking countries and it assess socioeconomic status of participants, is essential to assess this subject in non- English a questionnaire with 30 items, was used. The countries as well. The purpose of this study is to data was analyzed using Principle Component assess drug literacy level in Qazvin province in Analysis (PCA) method (36, 37, 38 and 39) Iran. The Single Item Literacy Screener (SILS) Then participants were categorized in 3 groups, method was used to do this study. (weak, moderate, and good), based on their socioeconomic status. Experimental The results were analyzed using SPSS.V.16.0. Descriptive analyses were used to calculate Materials and methods frequencies and Chi-square test was used to This study was a part of a larger project, a examine the relationship between qualitative survey of “Pattern of Utilization of Drug and variables while t-test was used for quantitative Pharmaceutical Services”. Data was collected variables. To determine the final associations from a random sample (based on proportional between drug literacy level and effective to size method) of 1104 participants from both variables, logistic regression model was used. rural and urban areas in 6 counties (Qazvin, Takestan, Alborz, Abyek, Boeen- Zahra, and Results Avaj) in Qazvin province during April 7 to June8, 2013. A questionnaire was designed 1104 individuals participated in this survey to collect demographic data (county, gender, who lived in 6 counties in Qazvin province: age, residing area, marital status, education, (Qazvin (584),Takestan(114), Boeen-Zahra job, basic and complementary insurance, (85), Alborz(217), Abyek(86), and Avaj(18). family size and socioeconomic status) as well 47.7% of participants were female.20.7% lived a single question for assessing health literacy in rural areas. Married participants were 72.6%. according to Morris, et al., method (33);(“How 85.6 % had basic health insurance. In addition, often do you need to have someone help you 37.3% had complementary health insurance. Job when you read instructions, pamphlets, or status showed that 43.7% of participants were other written material from your doctor or employed. The maximum family size was 7. The pharmacy?”) with emphasis on medications. mean age of participants was 34.7 years (SD Internal validity of questionnaire with respect 12.95). The mean of years of education was 9.8 to clarity, completeness, relevance, face and years (SD 4.02), and participants with education scoring fields was confirmed by experts. less than high school diploma were 80.4%. 27.8% The Cronbach’s Alpha analysis was used for of participants were in weak socioeconomic reliability test of the questionnaire and it was status. Overall, 30.3% of participants had found to be 0.869. inadequate health literacy. Characteristics of Inclusion criteria were: age over 15 years the participants and their relationship with drug old, having reading skill (at least 1 formal literacy (using Chi-Square and t-test) are shown year education), and lack of any disability that in Table 1. can prevent reading. Data was collected in To adjust the relationships between relevant subsequent interviews with households (up to 5 variables (p < .05, according to Table 1) and times) by trained interviewers. If the interview drug literacy, logistic regression method was attempts were unsuccessful, substituted random used. According to Table 2, age, educational sample was used. Data collection method led to attainment, county, residing area, and family a response rate of 100%. socioeconomic status showed significant Response choices of SILS were: 1-Never, relationship with drug literacy, while marital 2-Rarely, 3- Sometimes, 4-Often, and 5-Always. status as well as basic and complementary health Cutoff > 2 was used to identify limited drug insurance were ruled out.
219 Peiravian F et al. / IJPR (2014), 13 (supplement): 217-224
Table 1.General characteristics according to health literacy level. Characteristics Adequate health Inadequate health n(%) p- value* (n. of participants) literacy (%) literacy (%) Age (1104) 770 (69.6) 334 (30.3) .000 Gender (1104) .399 Male 577 (52.3) 396 (68.6) 181 (31.4) Female 527 (47.3) 374 (71.0) 153 (29.0) Marital status (1104) .000 Single 302 (27.4) 238 (78.8) 64 (21.2) Married 802 (72.6) 532 (66.4) 270 (33.6) Educational attainment (1104) .000
220 Health Literacy in Iran: The Experience of Using “The Single Item Health
Table 2. Final Logistic Regression Model for predicting low health literacy. 95% C.I. for OR* Characteristics Sig. OR* Lower Upper Age .000 .456 .328 .633 Single 1 Marital status Married .066 1.474 .975 2.228 >Diploma 1 Educational attainment Complementary health have complementary insurance 693 (62.7) 1 insurance status Not have complementary insurance 411 (37.3) .266 1.232 .853 1.778 .001 Family socioeconomic Weak 1 status Moderate .000 1.891 1.334 2.681 Good .072 2.996 .922 6.755 *OR: Odds Ratio Discussion and basic health insurance type. According to Table 2, after controlling confounding effect This is the first study to identify drug literacy of variables using logistic regression model, level and its relationship with other demographic findings showed that people were more likely to variables using SILS method in Iran. Level of have inadequate drug literacy if they are older (p= inadequate drug literacy in Qazvin province .000, OR= .456; 95% confidence interval (CI): was found at 30.3%. The main findings (Table .328- .633), have less educational attainment 1) showed the correlation between drug literacy (< Diploma) (p= .000, OR= -5.771; CI:-3.023- and age (p= .000), marital status (p= .000), 111.016), reside in rural area (p= .000, OR= educational attainment (p= .000), county (p= -2.245; CI: 1.475- 3.418), living in Avaj county .000), residing area (p= .000), basic health (p= .000) and weaker socioeconomic status (p= insurance type (p= .000), complementary health .001). insurance status (p= .000) and socioeconomic Today in Iran, elders have less educational status (p= .000). Moreover, those findings attainment, based on which they are expected to showed that there are no correlation between have inadequate drug literacy. Their ability to read drug literacy and gender, family size, job status and comprehend medical and pharmaceutical 221 Peiravian F et al. / IJPR (2014), 13 (supplement): 217-224 subjects is less than the others, which explains After adjusting the results using logistic the negative association between age and drug regression model, the relationship between literacy level. drug literacy and marital status, as well as basic People with less formal education are more and complementary health insurance was not likely to have difficulties in understand medical confirmed. and pharmaceutical reading materials. It seems The limitation of this study was the lack of that people who live in rural area and Avaj good accompany of some participants, especially county, have less educational attainment and that from urban areas, mostly in socioeconomic status makes them weaker in drug literacy. People in questions. 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